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ENTREVISTA TERAPIA OCUPACIONAL

ANTECEDENTES PERSONALES
Nombre completo ___________________________________________________
Edad _____________________________________________________________
Estado Civil ________________________________________________________
Ocupacin _________________________________________________________
Entrevistador y fecha entrevista: ________________________________________
ANTECEDENTES FAMILIARES
Padre_____________________________________________________________
Madre ____________________________________________________________
Con quin vive______________________________________________________
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Relacin con grupo familiar____________________________________________
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Relacin entre los padres _____________________________________________
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Genograma

ANTECEDENTES PSICOSOCIALES
Situacin socioeconmica ____________________________________________
Situacin legal ______________________________________________________
Ocupacin padre e ingreso ____________________________________________
Ocupacin madre e ingreso____________________________________________
Ocupacin familiares e ingreso _________________________________________
Factores de Riesgo VIF ( ) MI ( ) AS ( ) OH ( ) Drog ( ) Abandono ( )
Vagancia ( ) Otro ______________________
Descripcin________________________________________________________
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HISTORIA CLNICA
Periodo de Gestacin y Nacimiento
Embarazo de la madre _______________________________________________
Estado de nimo ____________________________________________________
Actitud de la pareja __________________________________________________
Problemas en el embarazo ____________________________________________
Periodo gestacin ___________________________________________________
Tipo de parto _______________________________________________________
Problemas en el nacimiento ___________________________________________
Lactancia materna __________________________________________________
Vnculo con la madre ________________________________________________
Vnculo con el padre _________________________________________________
Otro ______________________________________________________________
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Desarrollo Psicomotor
Control de la cabeza _________________________________________________
Posicin sentado ____________________________________________________
Gateo ____________________________________________________________
Marcha ___________________________________________________________
Control esfnter _____________________________________________________
Otro ______________________________________________________________
Anamnesis
Dg actual__________________________________________________________
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Inicio______________________________________________________________
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Desarrollo _________________________________________________________
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Tratantes anteriores _________________________________________________
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Tratamiento actual __________________________________________________
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Frmacos (nombre, gramaje, dosis por da)
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DESEMPEO OCUPACIONAL
Rutina diaria
Semana___________________________________________________________
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Fines de Semana ___________________________________________________
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Roles que desempea
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Desempeo ABVD
Higiene menor ______________________________________________________
Higiene mayor ______________________________________________________
Control esfnter _____________________________________________________
Uso del bao _______________________________________________________
Vestimenta_________________________________________________________
Comer ____________________________________________________________
Traslado___________________________________________________________
Descripcin ________________________________________________________
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Desempeo AIVD
Preparacin alimentos _______________________________________________
Medicacin ________________________________________________________
Uso del telfono ____________________________________________________
Cuidado de la casa __________________________________________________
Compras __________________________________________________________
Uso transporte _____________________________________________________
Manejo dinero ______________________________________________________
Descripcin ________________________________________________________
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Desempeo Descanso y Sueo


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Desempeo Escolar
Curso y colegio ____________________________________________________
Historia escolar ____________________________________________________
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Rendimiento _______________________________________________________
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Conducta __________________________________________________________
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Relacin con compaeros ____________________________________________
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Desempeo Juego
Tipo de juego ______________________________________________________
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Compaeros de Juego _______________________________________________
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Desempeo Ocio y Tiempo libre
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Actividades y roles de inters
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Desempeo Participacin Social
Relacin con grupos sociales __________________________________________
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Relacin con pares __________________________________________________
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Redes de apoyo
Familia y amigos ____________________________________________________
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Instituciones________________________________________________________
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Mapa de red / Ecomapa

Dificultades el desempeo ocupacional


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Expectativas de Intervencin
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IMPRESIN GENERAL
Conducta manifestada _______________________________________________
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Contacto visual _____________________________________________________
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Tipo de comunicacin ________________________________________________

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Conexin con la realidad _____________________________________________
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Postura corporal ____________________________________________________
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Arreglo personal ____________________________________________________
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Comentarios
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Impresin Diagnstica
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